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Journal of Advanced Nursing Mar 2024To explore parents' experiences of unsettled babies and medical labels. (Review)
Review
AIMS
To explore parents' experiences of unsettled babies and medical labels.
DESIGN
Qualitative systematic review, thematic synthesis and development of a conceptual model.
REVIEW METHODS
Systematic review and thematic synthesis of primary, qualitative research into parents' experiences of unsettled babies <12 months of age. 'Unsettled' was defined as perception of excessive crying with additional feature(s) such as vomiting, skin or stool problems. The Critical Appraisal Skills Programme (CASP) checklist was used to assess trustworthiness.
DATA SOURCES
Structured searches completed in CINAHL, Medline, Embase, PsychINFO and CochraneCT on 23 March 2022 and rerun on 14 April 2023.
RESULTS
Ten eligible studies were included across eight countries contributing data from 103 mothers and 24 fathers. Two analytical themes and eight descriptive themes were developed. Firstly, parents expressed fearing judgement, feeling guilty and out of control as a result of babies' unsettled symptoms and seeking strategies to construct an 'Identity as a "Good Parent"'. This desire for positive parenting identity underpinned the second analytical theme 'Searching for an explanation' which included seeking external (medical) causes for babies' unsettled behaviours.
CONCLUSION
Parents can become trapped in a cycle of 'searching for an explanation' for their baby's unsettled behaviours, experiencing considerable distress which is exacerbated by feelings of guilt and failure.
IMPACT AND IMPLICATIONS FOR PATIENT CARE
Insight gained from this review could inform interventions to support parents, reducing inaccurate medicalization. Health visiting teams supporting parents with unsettled baby behaviour could focus on supporting a positive parenting identity by managing expectations, normalizing the continuum of infant behaviours, reducing feelings of guilt or uncertainty and helping parents regain a feeling of control.
REPORTING METHOD
ENTREQ guidelines were adhered to in the reporting of this review.
PATIENT OR PUBLIC CONTRIBUTION
Parent input was crucial in the design phase; shaping the language used (e.g., 'unsettled babies') and in the analysis sense-checking findings.
PubMed: 38528428
DOI: 10.1111/jan.16166 -
Japan Journal of Nursing Science : JJNS Jul 2024Skin barrier dysfunction can trigger various skin disorders in older adults. Skin barrier assessment is essential for nurses and caregivers to prevent skin disorders;... (Review)
Review
AIM
Skin barrier dysfunction can trigger various skin disorders in older adults. Skin barrier assessment is essential for nurses and caregivers to prevent skin disorders; however, the evidence available for clinical assessment is limited. This systematic review aimed to clarify the risk factors of skin barrier dysfunction in older adults.
METHODS
This review adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The four databases were searched using multiple terms related to "aged" and "skin barrier." The search was initially run on April 19, 2023, and rerun on October 12, 2023. Peer-reviewed quantitative studies in English were included, with no publication time limit being set. Two reviewers assessed the risk of bias in a blinded and independent manner using JBI tools. Owing to the heterogeneity of the results, a narrative synthesis was performed.
RESULTS
Among the database-identified 4833 studies, 20 studies were included. The extracted factors were categorized as demographic characteristics, functional characteristics, chronic diseases, nutritional status, skin condition, and environmental factors. However, owing to high risk of bias and inconsistent results across studies, only chronic kidney disease and dry skin were considered risk factors for skin barrier dysfunction in older adults.
CONCLUSIONS
Assessment of chronic kidney disease and dry skin in daily skin care may guide the development of personalized skincare programs to maintain skin integrity in older adults. Furthermore, cohort studies that consider confounding factors and the reliability of measurements are needed for an in-depth investigation into skin barrier dysfunction and more risk factors.
Topics: Humans; Risk Factors; Aged; Skin Diseases; Aged, 80 and over; Female; Male
PubMed: 38516948
DOI: 10.1111/jjns.12597 -
Contact Lens & Anterior Eye : the... Jun 2024Demodex blepharitis, often overlooked in ocular surface disease, involves Demodex mites, prevalent ectoparasites on human skin. Current treatments may not effectively... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Demodex blepharitis, often overlooked in ocular surface disease, involves Demodex mites, prevalent ectoparasites on human skin. Current treatments may not effectively eliminate these mites, prompting a need for targeted therapies. Lotilaner, an antiparasitic agent, shows promise. This systematic review and meta-analysis assesses 0.25% lotilaner ophthalmic solution's efficacy in reducing Demodex mite populations and its impact on ocular surface inflammation in Demodex blepharitis patients.
METHODS
A comprehensive literature search was performed in the PubMed and Cochrane Library databases from inception until February 2024 to identify relevant trials investigating the use of lotilaner in patients with Demodex blepharitis. The included studies were assessed for quality, and a meta-analysis was conducted to determine the overall treatment effects of lotilaner. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated for binary variables. All statistical analyses were performed using the R Statistical Software.
RESULTS
Five studies met the inclusion criteria and were included in this systematic review and meta-analysis. Lotilaner demonstrated significant efficacy in Collarette Cure [OR = 6.64; 95 % CI 3.78 to 11.04; p < 0.00001, I = 62 %] %], clinically meaningful collarette reduction [OR = 6.21; 95 % CI 3.67 to 10.49; p < 0.00001, I = 90 %], and achieving at least 1-grade collarette improvement [OR = 5.12; 95 % CI (2.96 to 8.88); p < 0.00001, I = 90 %] compared to the placebo group. The treatment also resulted in mite eradication [OR = 6.18; 95 % CI 4.67 to 6.18; p < 0.00001, I = 34 %], reduction in mite density [OR = 9.37; 95 % CI 5.36 to 16.36; p < 0.00001, I = 84 %], and erythema cure [OR = 2.29; 95 % CI 2.24 to 3.39; p < 0.00001, I = 5 %] and composite cure [OR = 7.05; 95 % CI 3.66 13. 61; p < 0.00001, I = 11 %]. The study suggests that lotilaner is a promising therapeutic option for collarette and associated symptoms, but the high heterogeneity in some outcomes and limited long-term data warrant further research to confirm its effectiveness and safety.
CONCLUSION
This systematic review and meta-analysis provides robust evidence supporting the efficacy of 0.25% lotilaner ophthalmic solution in treating Demodex blepharitis. Approval of this targeted therapy represents a significant milestone in ophthalmology and offers a promising treatment option for patients with Demodex blepharitis. Eye care professionals should consider the potential benefits of lotilaner in managing and alleviating the symptoms associated with Demodex infestations on the eyelids. Further research and long-term follow-up studies are warranted to assess the safety and effectiveness of lotilaner in treating Demodex blepharitis.
Topics: Blepharitis; Mite Infestations; Randomized Controlled Trials as Topic; Humans; Animals; Eye Infections, Parasitic; Ophthalmic Solutions; Mites; Treatment Outcome; Antiparasitic Agents
PubMed: 38514290
DOI: 10.1016/j.clae.2024.102148 -
PloS One 2024Worldwide, surgery related deaths within 30 days of the procedure accounts the third contributor among all causes of deaths, with an estimated 4.2 million people... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Worldwide, surgery related deaths within 30 days of the procedure accounts the third contributor among all causes of deaths, with an estimated 4.2 million people annually and half of these deaths occur in low and middle income countries.
OBJECTIVE
To determine the pooled prevalence of surgical site infection following cesarean section and its predictors in Ethiopia.
METHODS
A systematic review and meta-analysis were conducted by using PRISMA guideline. An appropriate and comprehensive search of PubMed, MEDLINE, EMBASE, CINAHL, Google Scholar, HINARI and Scopus was done. This SRMA included all articles conducted in all regional state of Ethiopia reporting the prevalence/proportion/incidence of SSI after cesarean section and/or associated factors. All observational study designs were included in this SRMA. Articles which lack our outcome of interest: SSI following cesarean section and its predictors were excluded from this SRMA. The I2 statistic was used to quantify heterogeneity across studies. Funnel plot asymmetry and Egger's tests were used to check for publication bias. A random effect model was used to estimate the pooled prevalence of SSI. Adjusted Odds Ratio (OR) with 95% Confidence Interval (CI) was also considered to determine the association of identified variables with SSI. Statistical analysis was conducted using STATA version 17 software.
RESULT
Initially 6334 studies were identified and finally 19 studies were found eligible for the analysis. Studies with a score of 7 and above were included for the final systematic review and meta-analysis. The review was comprised of 14 cross sectional studies, 4 cohort and one case control studies. The pooled estimate of SSI in Ethiopia was 11.13% (95%CI, 9.29-12.97%). Prolonged labor (AOR = 3.16, 95% CI; (2.14-4.68)), chorioamnionitis (AOR = 4.26, 95% CI; (1.99-8.91)), prolonged PROM (AOR = 3.80, 95% CI; (2.51-5.62)), repeated vaginal examination (AOR = 3.80, 95% CI; (2.45-5.88)), decreased hemoglobin level (AOR = 4.57, 95%CI; (3.16-6.60)), vertical skin incision (AOR = 3.09, 95% CI; (2.04-4.67)) and general anesthesia (AOR = 1.82, 95% CI (1.21-2.75)) are significantly associated with SSI after cesarean section in Ethiopia.
CONCLUSION
SSI after cesarean section in Ethiopia is high. Prolonged labor, chorioamnionits, prolonged PROM, repeated vaginal examination, decreased Hgb level, vertical skin incision and general anesthesia were positively associated. Thus, evidence based intra-partum care should be practiced.
Topics: Pregnancy; Female; Humans; Surgical Wound Infection; Risk Factors; Ethiopia; Cross-Sectional Studies; Cesarean Section; Prevalence; Observational Studies as Topic
PubMed: 38512861
DOI: 10.1371/journal.pone.0296767 -
Arthroscopy : the Journal of... Mar 2024To report the clinical outcomes of arthroscopic debridement for the treatment of Kellgren-Lawrence (KL) grade I and II (mild) and III (moderate) knee osteoarthritis (OA)... (Review)
Review
PURPOSE
To report the clinical outcomes of arthroscopic debridement for the treatment of Kellgren-Lawrence (KL) grade I and II (mild) and III (moderate) knee osteoarthritis (OA) at a minimum 1-year follow-up.
METHODS
A systematic review of primary literature was performed in concordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using the Medline, Embase, and Cochrane databases for studies regarding arthroscopic debridement/chondroplasty for management of knee OA at a minimum 1-year follow-up. Studies were included if they included KL grades I to III or dichotomized clinical outcomes by KL grade. The primary outcome was patient-reported outcome measures (PROMs) at the final follow-up. Bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score.
RESULTS
Eight studies including a total of 773 patients met inclusion criteria (range of patients in each study, 31-214). Mean age of patients ranged from 35.5 to 64 years, with most studies having a mean patient age of 55 to 65 years. Mean follow-up ranged from 1.5 to 10 years. Seven of the 8 (87.5%) studies reported good to excellent PROMs at a minimum 1- to 4-year follow-up after arthroscopic debridement. Improvements in PROMs were superior in patients with less severe knee OA (KL I-II) in comparison to KL III in most studies. Conversion to arthroplasty ranged from 7.6% to 50% in KL III patients compared with 0% to 4.5% in KL I-II patients after arthroscopic debridement. Two of the 3 studies with at least a 4-year clinical follow-up reported that clinical improvements diminished with time (improvements no longer significant in total Western Ontario and McMaster Universities Osteoarthritis Index score). The lone randomized controlled trial was the only investigation that did not find a benefit of arthroscopic debridement over quality nonoperative care. MINORS scores ranged from 6 to 10 (mean, 8.0) for the 5 nonrandomized studies without controls.
CONCLUSIONS
Arthroscopic debridement for the management of mild to moderate knee OA is effective at short-term follow-up in patients who have exhausted conservative care. There is limited evidence demonstrating the durability of improvement following arthroscopic debridement after 2 years.
LEVEL OF EVIDENCE
Level IV, systematic review of Level I to IV studies.
PubMed: 38508289
DOI: 10.1016/j.arthro.2024.03.016 -
JAMA Dermatology Jun 2024Assessment of type, severity, and impact of dermatologic adverse events (DAEs) necessitates well-developed and validated clinician-reported outcome measures (ClinROMs)...
IMPORTANCE
Assessment of type, severity, and impact of dermatologic adverse events (DAEs) necessitates well-developed and validated clinician-reported outcome measures (ClinROMs) and patient-reported outcome measures (PROMs) that evaluate concepts specific to mucocutaneous toxic effects and that allow appropriate interpretation and comparison of DAEs across trials.
OBJECTIVE
To evaluate heterogeneity and quality of ClinROMs and PROMs used to assess DAEs from systemic cancer therapy.
EVIDENCE REVIEW
Two systematic reviews were conducted by searching PubMed and Embase databases from inception through March 7, 2023, and April 12, 2023. The first search included randomized clinical trials and observational studies reporting systemic cancer treatment-induced DAEs assessed by a ClinROM or PROM. The second included studies evaluating measurement properties of frequently used ClinROM and PROM instruments. The Consensus-Based Standards for the Selection of Health Measurement Instruments risk of bias tool was used to evaluate methodologic quality of validation assessments.
FINDINGS
A total of 395 studies were included. The Common Terminology Criteria for Adverse Events (CTCAE) was utilized in 331 studies meeting inclusion criteria (83.8%). At least 1 skin-related PROM was infrequently utilized in systemic chemotherapy clinical trials (79 studies [20.0%]). Most frequently utilized PROMs were the Dermatology Life Quality Index (DLQI; 34 studies [8.6%]) and Skindex-16 (20 studies [5.1%]). Among studies capturing DAEs, 115 (29.1%) reported a nondescript term (ie, rash) as the only DAE. Eight studies described 44 property assessments of the CTCAE, DLQI, and Skindex. There were no studies evaluating content validity, intrarater reliability, or measurement error for the CTCAE, DLQI, or Skindex. There were no studies evaluating structural validity, internal consistency, and responsiveness of DLQI or Skindex. Interrater reliability and responsiveness were each assessed for 1 DAE-related component of the CTCAE. Construct validity for CTCAE, DLQI, and Skindex was evaluated in 29 (65.9%), 3 (6.8%), and 9 (20.5%) assessments, respectively.
CONCLUSIONS AND RELEVANCE
In this systematic review, there was a narrow spectrum of ClinROMs and PROMs with limited validity for the measurement of DAEs in the context of systemic chemotherapy interventions in clinical trials. Report of trial DAEs often had low morphologic specificity and meaning. Based on existing gaps in measurement and report of DAEs, a frequent and impactful adverse event to chemotherapy, the framework for evaluating cutaneous toxic effects in oncology trials may need collaborative reevaluation.
Topics: Humans; Neoplasms; Patient Reported Outcome Measures; Antineoplastic Agents; Skin Diseases; Outcome Assessment, Health Care; Randomized Controlled Trials as Topic
PubMed: 38506826
DOI: 10.1001/jamadermatol.2024.0053 -
Cureus Feb 2024Burn injuries, a major global health concern, result in an estimated 180,000 fatalities annually. Despite tremendous progress in treatment methods over the years, the... (Review)
Review
Burn injuries, a major global health concern, result in an estimated 180,000 fatalities annually. Despite tremendous progress in treatment methods over the years, the morbidity and mortality associated with burns remain significant. Autologous skin grafting, particularly split-thickness skin grafting (STSG), has been a cornerstone in burn reconstruction, and it has facilitated survival and functional recovery for total body surface area (TBSA) significantly. However, the requirement for primary closure at the donor site due to the constraints of full-thickness donor harvesting continues to pose challenges. The introduction of dermal regenerative templates (DRT) in the late 1970s marked a substantial step forward in tissue engineering, addressing the inadequacy of dermal replacement with STSGs. This systematic review aimed to compare the outcomes of different graft types - bioengineered, autografts, allografts, and xenografts - in burn reconstruction over the last 24 years. The review focused on the pros and cons of each graft type, offering clinical insights grounded in experience and evidence. The approach involved a systematic review of studies published in English from January 2000 to January 2024, covering randomized controlled trials (RCTs), cohort studies, case-control studies, and case series. The participants comprised individuals of all ages who underwent burn reconstruction with skin grafts, specifically split-thickness grafts, full-thickness grafts, composite grafts, and epidermal grafts (autografts, allografts, and xenografts) and bioengineered grafts. The primary outcomes were functional and cosmetic results, patient satisfaction, graft survival, and complications. The risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2), the Newcastle-Ottawa Scale (NOS) for non-randomized studies, and the Canada Institute for Health Economics (IHE) quality appraisal tool for case series. Our initial search yielded a total of 1,995 articles, out of which 10 studies were selected for final analysis. Among the four clinical trials assessed, 75% showed a high risk of bias. The studies reviewed involved various graft types, with six studies (60%) concentrating on allografts, three (30%) on autografts, and one (10%) on bioengineered skin grafts. The outcomes were varied, underlining the intricate nature of burn wound management. Our evaluation revealed promising results for autologous-engineered skin substitutes and allografts but also highlighted methodological disparities among the studies included. The dominance of observational studies and the diversity of outcome measures present obstacles to direct comparisons. Future research should address these limitations, employing well-structured RCTs, standardized outcome measures, and exploring long-term outcomes and patient-specific factors. The rapidly evolving field of regenerative medicine offers great potential for novel grafting methods. This systematic review provides valuable insights into the diverse outcomes of burn reconstruction using different graft types. Autologous-engineered skin substitutes and allografts seem to hold significant promise, suggesting a possible shift in grafting techniques. However, methodological inconsistencies and the lack of high-quality evidence underscore the necessity for further research to fine-tune burn care approaches.
PubMed: 38496152
DOI: 10.7759/cureus.54277 -
Mycobacterium tuberculosis latent infection in healthcare students: systematic review of prevalence.Revista Da Escola de Enfermagem Da U S P 2024The aim of this study was to synthesize the evidence on the prevalence of latent Mycobacterium tuberculosis infection (LTBI) among undergraduate health care students. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of this study was to synthesize the evidence on the prevalence of latent Mycobacterium tuberculosis infection (LTBI) among undergraduate health care students.
METHODS
A systematic review of prevalence with meta-analysis was conducted. Prospective and retrospective cohorts and cross-sectional studies involving probable exposure to M. tuberculosis during undergraduate education, along with the tuberculin skin test (TST) or interferon-γ release assay (IGRA) for investigation of latent tuberculosis were searched. Searches were conducted in MEDLINE, CINAHL, EMBASE, LILACS, Scopus, and Web of Science databases. Independent reviewers were responsible for the selection and inclusion of studies. Data were extracted, critically appraised, and synthesized using the JBI approach. PRISMA was used to report the study.
RESULTS
Twenty-two studies were analyzed. The overall prevalence in healthcare undergraduate students was 12.53%.
CONCLUSION
The prevalence of LTBI in undergraduate health students was high for such a highly educated population. Screening with TST and/or IGRA and chemoprophylaxis, when necessary, should be provided to undergraduate health students when in contact with respiratory symptomatic patients.
Topics: Humans; Mycobacterium tuberculosis; Prevalence; Cross-Sectional Studies; Retrospective Studies; Prospective Studies; Latent Tuberculosis; Students
PubMed: 38488508
DOI: 10.1590/1980-220X-REEUSP-2023-0238en -
BMC Pregnancy and Childbirth Mar 2024This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection... (Meta-Analysis)
Meta-Analysis
Can the use of azithromycin during labour reduce the incidence of infection among puerperae and newborns? A systematic review and meta-analysis of randomized controlled trials.
OBJECTIVE
This systematic review and meta-analysis investigated whether the use of azithromycin during labour or caesarean section reduces the incidence of sepsis and infection among mothers and newborns.
DATA SOURCES
We independently searched the PubMed, Web of Science, Cochrane Library and EMBASE databases for relevant studies published before February, 2024.
METHODS
We included RCTs that evaluated the effect of prenatal oral or intravenous azithromycin or placebo on intrapartum or postpartum infection incidence. We included studies evaluating women who had vaginal births as well as caesarean sections. Studies reporting maternal and neonatal infections were included in the current analysis. Review Manager 5.4 was used to analyse 6 randomized clinical trials involving 44,448 mothers and 44,820 newborns. The risk of bias of each included study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions.Primary outcomes included the incidence of maternal sepsis and all-cause mortality and neonatal sepsis and all-cause mortality; secondary outcomes included maternal (endometritis, wound and surgical site infections, chorioamnionitis, and urinary tract infections) and neonatal outcomes (infections of the eyes, ears and skin). A random-effects model was used to test for overall effects and heterogeneity.
RESULTS
The pooled odds ratios (ORs) were as follows: 0.65 for maternal sepsis (95% CI, 0.55-0.77; I, 0%; P < .00001); 0.62 for endometritis (95% CI, 0.52-0.74; I, 2%; P < .00001); and 0.43 for maternal wound or surgical site infection (95% CI, 0.24-0.78; P < .005); however, there was great heterogeneity among the studies (I, 75%). The pooled OR for pyelonephritis and urinary tract infections was 0.3 (95% CI, 0.17-0.52; I, 0%; P < .0001), and that for neonatal skin infections was 0.48 (95% CI, 0.35-0.65; I, 0%, P < .00001). There was no significant difference in maternal all-cause mortality or incidence of chorioamnionitis between the two groups. No significant differences were observed in the incidence of neonatal sepsis or suspected sepsis, all-cause mortality, or infections of the eyes or ears.
CONCLUSION
In this meta-analysis, azithromycin use during labour reduced the incidence of maternal sepsis, endometritis, incisional infections and urinary tract infections but did not reduce the incidence of neonatal-associated infections, except for neonatal skin infections. These findings indicate that azithromycin may be potentially beneficial for maternal postpartum infections, but its effect on neonatal prognosis remains unclear. Azithromycin should be used antenatally only if the clinical indication is clear and the potential benefits outweigh the harms.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Azithromycin; Neonatal Sepsis; Cesarean Section; Chorioamnionitis; Endometritis; Incidence; Randomized Controlled Trials as Topic; Sepsis; Puerperal Infection; Surgical Wound Infection; Urinary Tract Infections
PubMed: 38486177
DOI: 10.1186/s12884-024-06390-6 -
BMC Palliative Care Mar 2024Children with life-threatening and life-limiting conditions can experience high levels of suffering due to multiple distressing symptoms that result in poor quality of...
BACKGROUND
Children with life-threatening and life-limiting conditions can experience high levels of suffering due to multiple distressing symptoms that result in poor quality of life and increase risk of long-term distress in their family members. High quality symptom treatment is needed for all these children and their families, even more so at the end-of-life. In this paper, we provide evidence-based recommendations for symptom treatment in paediatric palliative patients to optimize care.
METHODS
A multidisciplinary panel of 56 experts in paediatric palliative care and nine (bereaved) parents was established to develop recommendations on symptom treatment in paediatric palliative care including anxiety and depression, delirium, dyspnoea, haematological symptoms, coughing, skin complaints, nausea and vomiting, neurological symptoms, pain, death rattle, fatigue, paediatric palliative sedation and forgoing hydration and nutrition. Recommendations were based on evidence from a systematic literature search, additional literature sources (such as guidelines), clinical expertise, and patient and family values. We used the GRADE methodology for appraisal of evidence. Parents were included in the guideline panel to ensure the representation of patient and family values.
RESULTS
We included a total of 18 studies that reported on the effects of specific (non) pharmacological interventions to treat symptoms in paediatric palliative care. A few of these interventions showed significant improvement in symptom relief. This evidence could only (partly) answer eight out of 27 clinical questions. We included 29 guidelines and two textbooks as additional literature to deal with lack of evidence. In total, we formulated 221 recommendations on symptom treatment in paediatric palliative care based on evidence, additional literature, clinical expertise, and patient and family values.
CONCLUSION
Even though available evidence on symptom-related paediatric palliative care interventions has increased, there still is a paucity of evidence in paediatric palliative care. We urge for international multidisciplinary multi-institutional collaboration to perform high-quality research and contribute to the optimization of symptom relief in palliative care for all children worldwide.
Topics: Humans; Child; Palliative Care; Quality of Life; Terminal Care; Pain; Family
PubMed: 38481215
DOI: 10.1186/s12904-024-01367-w